Name__________________ Social Security Number_______________
The term County means the [Name of County Agency].
What am I authorizing the County to do by signing this authorization?
If I am found eligible to receive SSI benefits, I understand that I am authorizing the Commissioner of SSA to send to the County:
- My first retroactive post-eligibility payment of Supplemental Security Income (SSI) benefits, or
- An amount equal to the amount of reimbursable public assistance the County gave to me when law restricts the manner in which my SSI money can be released to me.
How will the County be paid for the reimbursable public assistance it gave to me?
If I am found eligible to receive SSI money, SSA will send my first retroactive post-eligibility SSI payment to the County or an amount equal to the amount of reimbursable public assistance the County gave to me when law restricts the manner in which my SSI money can be released to me. The County may:
- Deduct from my first retroactive post-eligibility SSI payment the sum of all County public assistance benefits made to, or on behalf of, me by the County in situations when law does not restrict the manner in which my SSI money can be released to me, or
- Have SSA send it an amount equal to the amount of reimbursable public assistance the County gave to me when law restricts the manner in which my SSI money can be released to me,
for months beginning with:
The first day of the month in which my SSI payments resume following a period of suspension or termination and ending with, and including the month my SSI payments resume, or
The following month if the County cannot promptly stop making its last public assistance payment to me.
The County cannot be reimbursed for assistance it gave to me if thatassistance was financed wholly or partly from Federal dollars.
How long is this authorization binding on the County and me?
This authorization is binding on me and the County for one calendar year beginning with the date the County received it. If the County does not notify SSA within thirty (30) calendar days of the date that I signed this authorization, the authorization is not binding on the County or me. Also, this form must be signed and dated by both a County representative and me to be avalid Agreement that authorizes the County to receive interim assistance reimbursement from my SSI payments.
However, if I file a timely request for an administrative or judicial review within the time permitted under SSA's regulations, this authorization will remain in effect, even if beyond the one calendar year period, until such timeas:
SSA makes the initial SSI post-eligibility payment following a suspension or termination of my SSI benefits; or
SSA makes a final determination on my appeal; or
The County and I both agree to terminate this authorization.
What rights and appeals are available to me under this authorization?
The County is required to:
Pay to me any balance due from the retroactive SSI payment within 10 working days of the receipt of my SSI payment.
Give me written notice explaining:
How much SSA repaid the County for interim assistance it gave to me;
The balance, if any, due me unless the Social Security Act requires SSA to pay me such balance. [In such an event, SSA will notify me of the manner in which the balance will be paid to me.]; and
That I will have an opportunity for a hearing with the County if I disagree with its actions regarding repayment of interim assistance or any action it took regarding this authorization.
_____________________________________ Date _________________
Signature of Member
_____________________________ Date _________GR Code________
Signature of County Representative